Our kidneys are essential to life. These two small organs work tirelessly to filter 180 litres of our blood per day and to remove waste from our bodies.

Kidney diet cornerstones: Fluid

One of the kidneys’ major functions is to maintain the fluid balance in your body. When your kidneys are not working well, they are not able to remove water as effectively.

Kidney diet cornerstones: Protein

Protein is a macronutrient important for your everyday health. It is composed of building blocks called amino acids and can be found in every cell of our bodies.

Kidney diet cornerstones: Potassium

Potassium is one of the main minerals found in your blood. It is also an electrolyte, which means it carries an electrical charge.

Kidney diet cornerstones: Phosphorus

Like calcium, phosphorus is a mineral that plays an important role in maintaining bone health.

Kidney diet cornerstones: Sodium

Sodium is a nutrient found in table salt. Consequently, salt has a high sodium content. It is naturally found in some other foods, but is also added during the preparation and processing of food for taste and preservation purposes.

Taking care of your kidneys

Kidney Diet Cornerstones: Fluid

Kidney Diet Cornerstones: Protein

Kidney Diet Cornerstones: potassium

Kidney Diet Cornerstones: phosphorus

Kidney Diet Cornerstones: sodium

Taking care of your kidneys

Our kidneys are essential to life. These two small organs work tirelessly to filter 180 litres of our blood per day and to remove waste from our bodies.

Kidney disease is the progressive loss of kidney function, ultimately leading to kidney failure. Unfortunately, the number of people with kidney disease is increasing in Canada and around the world.

Act now

It is very important to manage kidney disease with the help of a team of specialists, including a physician, dietitian, nurse and pharmacist. This team of people can tell you what you can do to slow or stabilize the progression of kidney disease. These measures include:

blood pressure control

blood sugar control (for diabetics)

smoking cessation

avoiding excess protein and salt

achieving or maintaining a healthy weight

taking precautions with products harmful to the kidneys, like non-steroidal anti-inflammatory drugs (NSAIDs),1 contrast agents that are used for certain medical examinations, and some natural products that are sold over the counter

It is important to tell your healthcare provider about all products you are taking, especially “natural” products that are sold without a prescription.

In summary, many measures to slow the progression of kidney disease do include medications, but there are also many things you can do yourself to keep your kidneys working as long as possible.

Nutrition

What you eat plays a major role in the treatment of kidney disease. The main goals of the kidney diet (also referred to as a renal diet and chronic kidney disease diet restrictions) are to meet your nutritional needs, reduce the accumulation of waste and slow the progression of kidney disease.

Watch for protein, salt and minerals

Controlling the amount of protein and salt (sodium) in your diet is an important first step. In some cases, the amount of minerals you consume (such as potassium and phosphorus) may also need to be reduced. Reading labels is very important and you may want to avoid phosphate additives in processed foods to protect your kidneys.

Making food from scratch using recipes like the ones in Spice it up! Giving zest to your renal diet (www.myspiceitup.ca) is a great way to avoid excess protein, sodium and additives.

An experienced dietitian should supervise any change to your diet, because maintaining good nutritional status is very important.

Control hypertension

High blood pressure and diabetes are the most common causes of kidney failure. Uncontrolled hypertension can speed up the progression of kidney disease. If you are taking a blood pressure medication, it is important to take it as prescribed by your doctor. As well, a low-salt diet can help control blood pressure.

It’s not enough to simply reduce the salt you are adding to your food with a salt shaker; you also need to limit hidden salt in processed foods and restaurant meals. Your daily sodium intake should not be higher than 2300 mg. Reading labels will help you to choose low-sodium foods.

In this article, we discussed the most important measures that will help slow the progression of kidney disease. However, kidney disease is very complex, and each of us is different. To ensure the best possible care, it is important that everyone with kidney disease is evaluated individually, this will often include personalized chronic kidney disease diet restrictions.

Adapted from the original by Céline Quintin, P.Dt.*
You can see the original document in PDF here.
*Céline Quintin is a registered dietitian who works with dialysis patients at Notre Dame Hospital in Montreal (CHUM). She is the past president of the Quebec Association of Nephrology Dietitians (RNNQ).
This article was first published in Spice it up! Love your kidneys, Special Edition 2016.
Available at www.myspiceitup.ca.
Reproduced with permission.

Kidney diet cornerstones: Fluid

Fluid and your kidneys

One of the kidneys’ major functions is to maintain the fluid balance in your body. When your kidneys are not working well, they are not able to remove water as effectively. If you take in more fluids than your body is able to get rid of, this can lead to a buildup of excess fluid, or “edema.” Excess fluid can be dangerous, as it puts a great strain on your heart.1

For patients on renal dialysis, it can be challenging to know what amount of fluid is right for their individual needs. Dialysis side effects such as too much or too little fluid can result in a fluid imbalance; this is not only uncomfortable, but may also put your health at risk. It is very important that you know how to recognize side effects of renal dialysis and if you are not in a healthy balance. Your registered dietitian will work with you to determine your fluid needs.

Possible signs and symptoms of fluid imbalance:*

Overhydration (too much fluid)

High blood pressure

Swelling (edema)

Cramping

Shortness of breath

Sudden increase in weight

Sudden drop in blood pressure on dialysis

Dehydration (too little fluid)

Low blood pressure

Dizziness

Cramping

Dry mouth

Excess fluid loss (i.e. vomiting, diarrhea)

Feeling thirsty

*Your healthcare team monitors your fluid status on a regular basis. Recognizing the signs and symptoms of your dialysis side effects such as having too much or too little fluid in your body enables you to work with your team to come up with a plan that keeps you as healthy as possible.

Fluid balance and types of dialysis treatment

Your dialysis treatment plays a significant role in how much fluid you can include in your diet. Fluid and diet restrictions for dialysis patients will vary. If you are on a home dialysis therapy such as peritoneal dialysis or home hemodialysis, you may not have the same fluid restrictions as someone who is receiving in-centre hemodialysis.

In peritoneal dialysis, fluid is removed daily. Patients may also continue to have urine output, which provides additional removal of water from the body.

In home hemodialysis, treatment hours can be extended or more frequent.1 These therapies often allow patients more flexibility with the amount of fluid they can include each day.

In-centre hemodialysis implies that most patients receive dialysis three times a week for four hours per treatment. This means fluid builds up between treatments and as a result, patients must be careful with how much liquid they consume.1

How to manage your fluid when on kidney dialysis

Managing your fluid can be challenging regardless of the type of dialysis, but it is possible. There are steps you can take to minimize fluid buildup and control your thirst.

Know your limit (and stay within it)
Rule of thumb when setting daily fluid targets is to aim for four cups plus the amount equal to how much urine you are making. If you have a larger body mass, your registered dietitian may calculate your fluid allowance based on 5% of your weight.1

You are what you eat (and drink)
Next to dialysis, food and fluid play the greatest role in keeping your water gains to a minimum.

Sodium
High sodium (salt) intake can make you feel thirsty and lead to increased fluid intake. Sodium also causes your body to hold on to extra water. Both can result in excess fluid buildup. Speak to your registered dietitian to learn how you can reduce sodium in your diet.

Fluid
Everything that is liquid at room temperature is considered a fluid and must be counted towards your daily allowance.

Common fluids:

Water

Juices/fruit drinks

Tea/coffee

Alcohol

Ice cream/sherbet

Soup

Ice

Pop

Milk

Nutritional supplements

Popsicles

Jello

Hidden fluid
You may also take in more fluid than you think. Hidden fluid can be found in all foods that contain water; some have more than others. While you do not count this as part of your daily fluid allowance, you may need to limit the portion size of foods with higher water content.

Question: Which food has the greatest amount of hidden fluid?

Green peas

Celery

Watermelon

Show me the answer

Answer: Watermelon

Tips for controlling fluid intake

Plan ahead

Measure how much liquid your favourite cups hold to help plan your fluid for the day.

Avoid drinking simply out of habit; save your fluid for when it is important to you.

Spread your fluid intake throughout the day.

Track your fluid

Keep a daily fluid diary. Measure and mark down each time you consume a fluid. Remember: small portions such as ice cubes add up quickly.

Freeze water or juice in ice cube trays. Frozen fluid can be more satisfying than the same portion in liquid form.

Be strategic

Take your medication with soft foods, such as applesauce. Save your fluid for liquids you enjoy. It’s important to check with your healthcare team to learn which pills you can have with your meals.

Replace liquids with frozen fruit when possible.

Choose foods that are liquid at room temperature less often.

Did you know? For every cup of liquid you drink beyond your daily fluid target, you will see half a pound of weight gain.1

Tips for controlling thirst

Limit salt, spicy food, caffeine and alcohol.

Add lemon or mint to cold water.

Replace water with plain or flavoured ice cubes. They longer and the options are endless.

Drink slowly and take small sips to make your fluid last longer.

Fruit including grapes and berries taste great frozen and help relieve thirst.

Use candy (hard or sour), gum or mints to increase saliva in your mouth. Speak to your dietitian for options that are right for you.

Ask your pharmacist about using breath spray or strips.

Other strategies

Dry mouth?Brush your teeth and rinse out your mouth with water or non-alcoholic mouthwash.

High blood sugar?This could make you feel thirstier. If you have diabetes, it is important to keep your blood sugar under control.

Dry air in your home?Use a humidifier to add moisture.

Hot summer day?Keep cool by staying indoors when possible or by spraying cold mist on your face and body.

How much fluid can I have?

The amount of fluid you can include each day will be different for everyone. Your type of dialysis treatment, urine output and other factors such as medications, body size and physical activity will be considered.1 Your registered dietitian will work with you to determine your fluid needs and your renal dialysis diet.

Adapted from the original by Christine Nash, MSc(C), RD, CDE*
Antonia Zettas, RD, CDE*
You can see the original document in PDF here. References:
Canadian Association of Nephrology Dietitians. Essential guide for renal dietitians; 3rd edition, 2010.
Canadian Nutrient File 2016. https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp.
*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Renal Dietitians (CAND).

Kidney Diet Cornerstones: Protein

What is it?

Protein is a macronutrient important for your everyday health. It is composed of building blocks called amino acids and can be found in every cell of our bodies. There are 20 amino acids that link together in different forms to carry out specific body functions including the building, maintenance and repair of tissues.1

Protein, your kidneys and dialysis

When protein is broken down and used by our body, it creates a waste product called urea. Healthy kidneys act as a filter to remove urea, fluid and other waste products from the body through urine. When you are on dialysis, your kidneys are no longer able to filter out enough fluid and waste.2 You must rely on your treatment to keep you safe.

Patients on kidney dialysis require more protein in their diet. This is because a certain amount of protein is removed during the treatment process. The type of dialysis you are receiving can affect how much protein you should include each day. In peritoneal dialysis, protein is removed on a daily basis. In home hemodialysis, treatment hours can be extended or more frequent, causing additional protein losses. This means patients on home dialysis therapies may require more protein than those who are receiving in-centre hemodialysis 3 times per week.3

Protein and your diet

Eating enough protein can be challenging. Lack of appetite, altered taste, low energy (fatigue) and financial issues are just some of the barriers that prevent patients from meeting their daily needs. Over time, this can lead to protein malnutrition, resulting in loss of muscle mass and decreased strength. It may also make it difficult to fight infections. Try these strategies to help you meet your goals:

Spread protein throughout the day

Eat the protein sources on your plate first

Choose protein options you enjoy

Hide protein in your dishes by adding small pieces to soups, salad or pasta

Adding a nutritional supplement can be beneficial when you are unable to meet your protein needs through dietary sources. There are many options on the market including nutrition drinks, protein powders and gels. Speak with your registered dietitian about which ones fit with your renal dialysis diet.

Types of protein

Choosing the right type of protein is just as important as eating the right amount of protein each day.

Complete protein

“Complete” proteins are animal-based and contain all of the essential amino acids your body is unable to make on its own. They are also easy for your body to absorb and use. Examples of complete proteins include fresh meat, poultry, fish, eggs and dairy.5 It is recommended that at least 50% of your total daily protein intake should come from these sources.4

Did you know?

When meats are labelled as “seasoned,” it means they have been injected with sodium, phosphorus and/or potassium and should be avoided if possible.6,7

Incomplete protein

“Incomplete” proteins are plant-based and while nutritious, they do not contain all of the essential amino acids. A variety of incomplete proteins must be eaten throughout the day for the body to use them efficiently. These include legumes, nuts, seeds, breads and cereals.8 Some plant-based foods are also higher in potassium and phosphorus and may need to be limited in your diet. Your registered dietitian will work with you to find the right balance.

Fast factSoy products such as tofu have the similar quality of protein as animal products. Try adding tofu into a vegetable stir-fry for more variety.9

True or false? If you are on any type of dialysis, it is NOT possible to follow a vegetarian diet.
a) True
b) False

Show me the answer

Answer: b) False. It is possible to follow a vegetarian diet but you need to work with your registered dietitian to ensure you keep your blood levels safe while meeting your high protein needs for dialysis.

Portion size

Once you know how much protein you need, how do you achieve this? The table below can help guide you by providing examples of approximate serving sizes for common protein sources.10

1 OUNCE

2 OUNCES

3 OUNCES

1 large egg or 2 egg whites

12 medium shrimp

1 pork chop

¼ cup shredded cheese

½ cup ricotta or cottage cheese

½ cup canned tuna

40g roasted chicken breast, sliced

1 medium chicken drumstick

cooked fish; size of a chequebook

*2 tbsp peanut butter

½ cup cooked ground beef or poultry

cooked beef or poultry; size of a deck of cards

*½ cup cooked beans

*⅔ cup Greek yogurt

*1 cup regular or firm tofu

*These products are rich in potassium and/or phosphorus for the amount of protein they provide. Your registered dietitian can work with you on how to fit these foods safely into your diet.

Daily protein intake for dialysis patients

The amount of protein you can include in your diet will be different for everyone. Your dietary habits and type of dialysis treatment, along with other factors such as your nutritional status, weight, presence of infection and other medical conditions must be considered. Your registered dietitian will work with you to determine your needs and develop a personalized nutrition care plan and dialysis diet menu.

Adapted from the original by Christine Nash, MSc(C), RD, CDE*, Antonia Zettas, RD, CDE*
You can see the original document in PDF here

*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Renal Dietitians (CAND).

Kidney Diet Cornerstones: Potassium

What is it?

Potassium is one of the main minerals found in your blood. It is also an electrolyte, which means it carries an “electrical charge.” This charge helps your body carry out many important functions, including muscle contractions and maintaining a normal heart rate, both of which are necessary for a healthy heartbeat. It also plays a key role in metabolism, which converts the nutrients from our food into energy we need for our bodies.

Potassium and dialysis

The kidneys play an important role in maintaining safe levels of potassium in the blood. When you are on kidney dialysis, your kidneys are no longer able to balance potassium as efficiently. Many different factors can cause potassium levels to become too high or too low. This can be dangerous to your heart and may even cause it to stop working.

Potassium and your diet

Nutrition is central to managing your blood potassium levels on dialysis. There are several things you can do with your diet to help keep your blood potassium at a safe level:

FOOD CHOICES
Potassium can be found naturally in most foods, but some contain much higher amounts than others. For example, a ½ cup of sliced kiwi contains 3 times as much potassium as a ½ cup of diced pineapple.1

It is important to remember that everyone’s potassium needs are different. Foods you may be asked to limit or increase in your diet may not be the same as others. Your registered dietitian will work with you to develop an eating plan that is right for you.

PORTION SIZE
When it comes to potassium, serving size matters. Having a large amount of a low-potassium food can turn it into a high-potassium food. For example, one serving of 10 cherries is a low-potassium option. But if you have two servings (i.e. 20 cherries), the potassium content is the same as a small banana!1 On the other hand, higher potassium foods may fit into your diet if eaten in smaller amounts.

READING LABELS
When choosing packaged foods, reading labels can help you determine how much potassium they contain. It is important to know that manufacturers are NOT required to report potassium in the Nutrition Facts Table.2 Just because the quantity is not included doesn’t mean the product is potassium-free! Some foods also contain potassium additives, which can contribute a large amount of potassium to your diet.3 Reading the ingredient list can help you identify what is in the product.

FOOD PREPARATION
Potassium can be removed during the process of canning fruit and cooking vegetables.4,5 This may allow you to add more variety to your diet. For example, a ½ cup of canned papaya contains 2.5 times less potassium than a ½ cup of fresh papaya.1 Soaking and/or double boiling root vegetables can also remove extra potassium.5,6

Quick tip:Watching your sugar intake? Be sure to drain the syrup or choose canned fruits that are packed in water.

Peel and cut potatoes in small cubes, put them in a large pot, and cover them with cold water.

Bring them to a boil. Remove the pot from the stove and drain the water.

Add fresh water to cover the potatoes.

Bring to a boil a second time, reduce heat, and simmer until potatoes are tender.

Drain and discard the water.

Potassium and your dialysis treatment

Your dialysis treatment also plays a role in how much potassium you can include in your diet. If you are on a home dialysis therapy such as peritoneal dialysis (PD) or home hemodialysis (HHD), you may not have the same potassium restrictions as someone who is receiving in-centre hemodialysis (IHD).

In PD, potassium is removed on a daily basis. Many patients also continue to have urine output, which provides additional removal of potassium from the body. In HHD, treatment hours can be extended or more frequent.8 These therapies often allow patients more flexibility with the amount of potassium-rich foods they can include in their diet.

In IHD, most patients receive dialysis 3 times a week for 4 hours per treatment. This means potassium can build up between renal dialysis sessions and as a result, patients are often required to limit their potassium intake.8

How much potassium can I have?

The amount of potassium you can include in your diet will be different for everyone. Your dietary habits and type of dialysis treatment, along with other factors such as medications and urine output must be considered.8 Your registered dietitian will work with you to determine your needs and develop a personalized nutrition care plan and dialysis diet menu plan.

Adapted from the original by Christine Nash, MSc(C), RD, CDE*, Antonia Zettas, RD, CDE*
You can see the original document in PDF here

*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Renal Dietitians (CAND).

Kidney Diet Cornerstones: Phosphorus

What is phosphorus?

Like calcium, phosphorus is a mineral that plays an important role in maintaining bone health.

Phosphorus and your kidneys

Healthy kidneys normally eliminate excess phosphorus through the urine to maintain equilibrium in the blood. However, as kidney function deteriorates, the amount of phosphorus in the blood may increase. High levels of phosphorus in the blood may cause your bones to become fragile, weak, or damage your blood vessels.

Phosphorus and your diet in chronic kidney failure

In cases of kidney failure, dietary potassium intake must be controlled in order to maintain an adequate phosphorus level. Phosphorus can be found in many foods. It is impossible to cut it out completely, but you may have to limit your intake of foods with moderate or high quantities of phosphorus.

In food, phosphorus exists in two forms:

Organic phosphorus

Type of phosphorus naturally occurring in food.

Found both in animal and plant-based foods.

On average, the body absorbs 40% to 60% of ingested organic phosphorus.

Organic phosphorus sources

Meat, poultry, fish

Eggs

Dairy products

Legumes

Whole-grain products

Nuts and seeds

Chocolate

Since most foods with high quantities of phosphorus are also sources of protein, you should continue to eat a certain amount of these foods for your health. Your nutritionist can help you develop a plan with recommended quantities of these foods based on your needs.

Inorganic phosphorus (hidden phosphorus)

Type of phosphorus that is added during food processing in the form of additives such as preservatives, flavour enhancers, food colouring, etc.

This type of phosphorus is found in many processed, ready-to-eat, and fast foods.

It is the most concerning source of phosphorus since 90% of inorganic phosphorus is absorbed by the body.

The more a food is processed, the more “hidden” phosphorus it may contain.

How to identify phosphorus additives in food?

Phosphorus levels are not always indicated in the nutrition facts table on food products. However, even if phosphorus is not listed, it could still be present in the product. Read labels carefully! Look for words like “phosphate” and “phosphoric” and “phosphite” in the ingredients list.

Most common phosphorus additives

Sodium phosphate, potassium phosphate

Phosphoric acid

Tricalcium phosphate

Sodium hexametaphosphate

Sodium tripolyphosphate

Phosphorus and types of dialysis treatment

Since peritoneal dialysis and standard hemodialysis in a hospital setting only eliminate a small amount of the phosphorus in your blood, it is important to control your dietary phosphorus intake even with renal dialysis. However, home hemodialysis, given the longer duration of dialysis, removes more phosphorus from the blood, therefore providing more leeway in dietary phosphorus intake.

Medications to control phosphorus level

Limiting dietary phosphorus intake alone does not necessarily prevent phosphate levels from increasing. Your doctor may prescribe drugs called “phosphate binders” if needed. These drugs bind to the phosphorus in your intestine and some of the phosphorus is then excreted in your stool. For these binders to work properly, they must always be taken with a meal or snack, preferably in the middle of your meal or snack. Do not take phosphate binders at the same time as iron supplements.

What is a safe level of phosphorus in my blood?

A normal blood phosphorus level is 0.8 to 1.45 mmol/L but your target level may be different. Speak to your doctor or nutritionist about this.

*Annie Morin is a registered nephrology dietitian at the nephrology and home dialysis outpatient clinic at the Laval integrated health and social service centre (IHSSC) (Centre intégré de santé et de services sociaux de Laval [CISSS]).

Kidney Diet Cornerstones: Sodium

What is sodium?

Sodium is a nutrient found in table salt. Consequently, salt has a high sodium content. It is naturally found in some other foods, but is also added during the preparation and processing of food for taste and preservation purposes.

A high sodium intake increases the risk of high blood pressure, which may in turn lead to several other related health problems, like kidney disease. A high sodium intake also increases the risk of water retention in the body and increases thirst. Thus, people who already have a fluid restriction may find it harder to limit their fluid intake.2

Since a lot of the salt we consume is hidden in food, most Canadians consume far too much sodium (without even factoring in salt added while eating or cooking).1

Consequently, a reduced salt intake can help prevent or control high blood pressure, while protecting the kidneys.

Nutrition facts table on food

Using the nutritional value table on processed food is of utmost importance when trying to limit sodium consumption.

For information, a daily value of 5% or less indicates a low sodium level, whereas 15% or more indicates a high sodium level.3

How to manage/reduce your sodium intake

Opt for minimally processed foods.

Use lemon, garlic, spices, and fine herbs to season your food so you can avoid using salt while eating or using too much while cooking.

Use garlic, onion, or celery powder, or use salt-free seasoning mixes.

Make your own broths or use store-bought ones with no salt added to cook and prepare soups.

Use condiments like mustard, ketchup, relish, chili sauce, and Worcestershire sauce in small quantities as opposed to condiments with a high salt content like soy sauce, tamari sauce, and packaged or canned sauces.

Choose thinly sliced meats and home-cooked chicken or fish to replace cold cuts and smoked or salted fish or other types of meat.

Rinse canned foods or opt for salt-free canned items.

Ask your nutritionist for salt-free snack ideas to cut back on chips and other salty snacks.

How much sodium can I eat?

Your sodium intake may vary depending on the condition of your kidneys (chronic kidney disease stage) and your therapy modality, and other health conditions. It is important to learn to read labels to choose foods that are low in salt or that are naturally salted. Your nutritionist will guide you in your learning process, assess your needs, and draw up a personalized nutritional care plan and dialysis meal plan.